32A-058 (10) ¢(NAMPJ,
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m DEPARTMENT OF BUILDD�,,C; INSPECTIO�INS
212 Alain Street ' Municipal Building
Northampton, Mass. 01060 'v
WORKER'S COMPENSATION VgSURANCE AFFIDAVIT
I, Nelson Shifflett, Valley Home Improvement, Inc .
(licenseripe,mittee)
with a principal place of business/residence at:
340 Riverside Dr. , Northampton, MA, 01060 (phone,) 584-7522
do hereby certiry, udder the pair L-id penalties of penury,
(g) I am an employer providing the following worker's compensation coverage for my
employees wor'ting on this job:
Acadia Insurance Co. 0109302-11 2/1/06
(Insunanc-- Company) (Policy?tu=ber) (Expiration Daze)
( ) i am a sole proprietor, geaeral contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
Nae of Con=,-tor) (Insu-ance Conipany?olicy Nulni cr) t��t iration Date)
m trac
(Name of Contraor) ;lnstlran(-- ComoauyiPolicy Number) (Ixpiration Date)
--i;hame of Contmctor) -- (Iasurance Companylpoucy?iuulb<:) (Expir.tion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(auach udd?jon l shoot if necessary to include i fazuaftoa paminiug w till oDatmttors)
( ) I am a sole proprietor and have no one worlang for me.
( ) I am a home owner performing all the work myself.
NOM please be aware this while homeowaen who empicy pe som to do mai�consaucdon or repair work on a dwelling of
not mote thaw throe traits is which the homoownrr r=d=or an the gvaads appurt ,Ant thereto are oot gmaally coandered to be
employers under the work=`s compasatioa Act(GLl52.ss 1(5)),application by a homcowarr far a liceme or permit may m idcnoe the
legal Raba of an employer under the Workeez Compemation Act.
1 understand tbat a copy of this csatemeat may be for%w%i*d to the Depwtrrat of Ind L..e isl A=doa&Offroc of irrrrrance for the
coverage ve ificatioo sad that Lihtre to seen=coverage under soction 25A of MGL 152 can lead to t'Je imposition of cr=izW pemltiea
ooesixing of a fine of up to SI.500.00 and/or imp;iso�of up to one yew and civil penalties in the form of a Stop Work Order and a
Lae of S 100.00 a dly agniast tnc. /7
Signed _��ti2.y of���p� rM..dgmtaoas,l use only
Si ed this I
mit Numbcr
' Lot#
/V /-5oll S`i`// G,IZ %
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SECTION 8 -CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable
Name of License Holder : Ne130n Shiff1 t 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive Northam on, MA O'I n60 9/22/06 ----
Address Expiration Date
584-7522
Signature f Telephone
l
9 Registered Home Improvement Contractor: Not Applicable ❑
Valle.} Home Impro-vement" Inc_ 105543 _
Company Name Registration Number
340 Riverside Drive _7L17/A
Address Expiration Date
Northampton, MA 01060 Telephone 584-7522
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidav't
will result in the denial of the issuance of the building permit. �
I
Signed Affidavit Attached Yes....... 20 No...... ❑ i
11. - Home Owner Exemption
The current exemption for"homeowners"vvas extended to include Owner-occupied Dwellings of one(1) or tnvo(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780. Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is, or is intended to be, a one or two family dwelling,attached or detached structures accessory to such use and or farm
structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of titassachusetts General Laws Annotated.
Homeowner Signature
.
'ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding j ] Other [ ]
t
Brief Description of Proposed Work: V'A0 �ui0 BOCA+k rc>�wl
Alteration of existing bedroom Yes 11� No Adding new bedroom Yes No
Attached Narrative _: Renovating unfinished basement Yes No
Plans Attached Roll _ - Sheet.
sa. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
i
c. Is there a garage attached?
d. Proposed Square footage of new construction. _ Dimensions
e. Number of stories?
f. Method of heating? _ Fireplaces or 'Noodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
ype of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
i
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
C'ug -76 ✓n m T Z as Owner of the subject property
f
hereby authorize Nelson Shifflett, Valley Home Improvement, Inc, _ to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Da e
1, Nelson Shifflett Valley Home IMprovement, Inc- as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Nelson Shifflett
Print Name
s
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. re
N there any proposed changes to or additions of signs intended for the property ?YES _
No
IF YES, describe size, type and location:
r
i
Department"use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
v6 212 Main Street Sewer/Septic Availabllity
" >= Room 100 Water/Well Availability-
Wl ha pion, MA 01060 Two Sets of Structural Plans
phone 413--x°87.1240 Fax 413-587.1272 Plot/Site Ptans� = r
Other S r
APPLICA'T'ION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 2 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
-- v� Map Lot Unit
Zone Overlay District
C1 � Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: j 01716 S/
—
Name(Print) ` Curren':Mailing Address: T--
Te!ephone
Signature
2.2 Authorized Agent: Nelson Shifflett
Valley Home Improvement. Inc. P.O. Box 60627, Florence, ?4A 01062
Name(Print) Current Mailing Address
J1 6111-41W _584-7522
Signature Teie_phone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 2� Q 0 o (a) Building Permit Fee
2. Electrical 1 1500 (b) Estimated Total Cost of
Construction from 6
3. Plumbing 3 5 0 Q Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) '2�, C? t� Check Number 6J`"� '"
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
50 UNION ST BP-2006-0757
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32A-058 CITY OF NORTHAMPTON
Lot: -029
Permit: Buildinq
Category: BUILDING PERMIT
Permit# BP-2006-0757
Project# JS-2006-1162
Est. Cost: $25000.00
Fee: $125.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Valley Home Improvement, Inc 105543
Lot Size(sg.ft.): 0.00 Owner: AGNA GWEN&THOMAS MARANTZ
Zoning.URC Applicant: Valley Home Improvement, Inc
AT: 50 UNION ST
Applicant Address: Phone: Insurance:
P O Box 60627 (413) 584-7522 Workers
Compensation
FLORENCEMA01062 ISSUED ON:113012006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL 2 BATHROOMS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Sienature:
FeeType• Date Paid: Amount:
Building 1/30/2006 0:00:00 $125.0020594
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo